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eLetters

24 e-Letters

The correct statement is as follows:
The portion of the stomach within which H. pylori localises has profound
impact on its clinical sequelae. H. pylori colonization of the antrum
results in increased acid production which may lead to duodenal ulcer
formation. On the other hand, infection within the body of the stomach
predisposes individuals to atrophic gastritis, which, in turn, may
progress to precancerous lesions a...

The correct statement is as follows:
The portion of the stomach within which H. pylori localises has profound
impact on its clinical sequelae. H. pylori colonization of the antrum
results in increased acid production which may lead to duodenal ulcer
formation. On the other hand, infection within the body of the stomach
predisposes individuals to atrophic gastritis, which, in turn, may
progress to precancerous lesions and gastric cancer.

Thanks

Conflict of Interest:

The article states:
=======================================================The portion of the
stomach within which H. pylori localises has profound impact on its
clinical sequelae.18 H. pylori infection within the body of the stomach
results in increased acid production and peptic ulcer disease. On the
other hand, infection of the antrum predisposes individuals to atrophic
gastritis, which, in turn, may progress to preca...

The article states:
=======================================================The portion of the
stomach within which H. pylori localises has profound impact on its
clinical sequelae.18 H. pylori infection within the body of the stomach
results in increased acid production and peptic ulcer disease. On the
other hand, infection of the antrum predisposes individuals to atrophic
gastritis, which, in turn, may progress to precancerous lesions and
gastric cancer. =======================================================

The gastric location of the above statements is incorrect and
reversed. Infection of the antrum, not body, results in increase acid
production leading to ulcer disease. Vice-versa, infection of the body,
not antrum, results in atrophic gastritis and may lead to malignancy.

Thanks

Conflict of Interest:

I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.

I would like to share the experience in our country. Singapore is a country in Sout...

I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.

I would like to share the experience in our country. Singapore is a country in South-East Asia. All public hospital junior staff communicate via mobile technology. There are no bleeps. Mobile technology is an essential communication tool. A majority of junior doctors, housemen and medical officer grades are employed by a government-linked company, which gives out monthly mobile phone subscription fee subsidies. Mobile phone numbers of doctors are published on the hospital intranets. As the mobile phones are always with the doctors, each doctor is more easily accessible and can attend to patients in a swifter manner, potentially improving patient care. Consequently, many doctors carry two mobile phones around - a personal phone and a work phone. The same work mobile phone with an internet subscription allows the doctor to access journals, articles and databases literally at his finger tips.

There is potential in mobile technology and I urge interested parties to embrace it.

I read with interest the manuscipt by Jeyaruban and colleagues.
However I am disappointed that a major issue identified was a "Failure of
adherence to lifestyle changes".

There is scant evidence that lifestyle changes have any clinically
relevant impact on gout management.

Surgical weight loss is one of the few non medication related
interventions that has a substantial impact on serum urate.

The American College of Rheumatology recognised this in the 2012 ACR
Gout guidelines by saying "the TFP [Task Force Panel] recognized that diet
and lifestyle measures alone provide therapeutically insufficient serum
urate-lowering effects and/or gout attack prophylaxis for a large fraction
of individuals with gout".

One of the problems with lack of high quality gout care in Australia
in my opinion is the undue emphasis on non-evidence based interventions,
that, even if effective (which they have not shown to be yet), have a
small effect size. This is often to the detriment of emphasis on effective
evidence based therapies (all of which are currently medication based).

A focus on effective evidence based therapies would likely lead to a
better level of gout care by all involved with caring for these patients.

Conflict of Interest:

We are living a new epoch all over the world. Also in clinical
medicine. As it is known, for example, the model of a single doctor
participating heavily at each step of treatment is giving way to expanded-
care teams.

Moreno-Rodriguez identified an universal crisis of the clinical
method, with dangerous consequences in the practice of medicine. Among its
main causes there are: a deteriora...

We are living a new epoch all over the world. Also in clinical
medicine. As it is known, for example, the model of a single doctor
participating heavily at each step of treatment is giving way to expanded-
care teams.

Moreno-Rodriguez identified an universal crisis of the clinical
method, with dangerous consequences in the practice of medicine. Among its
main causes there are: a deterioration in the doctor-patient relationship,
the undervaluation of clinics, the process of specialization, the
overvaluation of technology, and the indifference for general medicine.
(1)

Moreover, the rigid implementation of guidelines and protocols
adopted as an "standardized new medicine", tend to favor a person "non-
centered" medicine. (2) So, the doctor/patient relationship has been
diluted. These elements are more evident in the elderly patients, usually
with several chronic conditions, when they attend to Emergency
Departments,.

The case referred by John Launer in the Postgraduate Medical Journal
recently is common in the Casualty Departments of great general hospitals.
(3) In order to minimize these situations in our Hospital General
Universitario Dr. Gustavo Aldereguia Lima, daily emergency teams are
carefully planned with enough number of specialists in Internal Medicine,
Emergency Medicine, General Surgery, Traumatology, and the main
specialties of the center, all of them working at the same local of this
service, besides residents and internships. Specialists supervise -joined
with nurses- the continuous care of the patients that stay for abnormal
long periods in this department and in a beside Observation room, and
decide the final output of them: return to the community or admission to
the hospital wards.

No one system is perfect, but the knowledge of this new scenario in
clinical medicine, with the possibility to order different tests -many of
them unnecessary- particularly by the young doctors, (4) and the care
segmentation by different doctors of several specialties, is the first
step to avoid tortuous evolution in this new context.

As a BMJ Editor's choice several years ago expressed: "What is it
that doctors offer that other professionals cannot? Diagnosis, diagnosis,
diagnosis," so for good results the clinical gist in essential, (5)
including the indispensable humanitarianism of our profession.

Conflict of Interest:

Promoting healthy eating certainly needs to be a greater priority
within the NHS but I suspect changing culture will be easier said than
done.
I the hospital I worked at last year, the central point of the hospital
was a Greggs. There was no canteen and whilst there was a cafe selling
healthier food above the Greggs I found many patients did not know it
existed and for the staff it did not have the same opening hours as...

Promoting healthy eating certainly needs to be a greater priority
within the NHS but I suspect changing culture will be easier said than
done.
I the hospital I worked at last year, the central point of the hospital
was a Greggs. There was no canteen and whilst there was a cafe selling
healthier food above the Greggs I found many patients did not know it
existed and for the staff it did not have the same opening hours as
Greggs. This makes healthy eating in this context the more difficult
option, especially as its location is so central to the hospital, it makes
it hard to ignore. Changing this would involve a massive overhaul in the
structure and culture of the hospital, especially as it is reportedly the
second busiest Greggs in the country(1)
It is not just availability of healthy food in the hospital however than
needs the be made easier, in hospitals where there are limited choices of
food options out of hours, many choose to send relatives or parents to
local shops for food. Frequently the only places open out of hours are
fast food restaurants and take-aways. In fact in another hospital I have
worked at, there was a fish and chip shop opposite the hospital which
boasted 'low calorie oil' and advised people the 'look after their heart'
by eating there. A cross-sectional study in the BMJ last year found that
just living or working in close proximity to fast-food restaurants (2)
I feel it is not just hospitals but a whole cultural shift that needs to
occur to promote healthier eating in this country.

Conflict of Interest:

I read with interest the article "Physical activity is medicine for
older adults" by Taylor in the Postgraduate Medical Journal (1). I agree
that physical activity is and remains an organismic necessity and the best
buy for public health (2-3)!

The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements...

I read with interest the article "Physical activity is medicine for
older adults" by Taylor in the Postgraduate Medical Journal (1). I agree
that physical activity is and remains an organismic necessity and the best
buy for public health (2-3)!

The German physician Christopher William Hufeland (1762 - 1836) wrote
in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the
movements is the grand foundation on which health, uniformity of
restoration, and the duration of the body, depend; and these certainly
cannot take place if we merely sit and think. The propensity to bodily
movement is, in man, as great as the propensity to eating and drinking.
Let us only look at a child. Sitting still is to it the greatest
punishment. And the faculty of sitting the whole day, and not feeling the
least desire for moving, is certainly an unnatural and diseased state. We
are taught by experience, that those men attained to the greatest age, who
accustomed themselves to strong and incessant exercise in the open air. I
consider it, therefore, as an indispensable law of longevity, that one
should exercise, at least, an hour every day, in the open air."(4)

Conflict of Interest:

In history of exercise physiology is often forgotten that Susruta of
ancient India was the first physician to prescribe physical activity for
health reasons. He promoted dietary changes and daily exercise of moderate
intensity such as brisk walking to minimize the consequences of diabetes
and obesity (1). Today, elderly people are very likely to benefit even
from simple, full-body exercise...

In history of exercise physiology is often forgotten that Susruta of
ancient India was the first physician to prescribe physical activity for
health reasons. He promoted dietary changes and daily exercise of moderate
intensity such as brisk walking to minimize the consequences of diabetes
and obesity (1). Today, elderly people are very likely to benefit even
from simple, full-body exercises, such as rising from a chair and sitting
back down again (10 repetitions, two to three times a day).

1. Tipton CM. Susruta of India, an unrecognized contributor to the
history of exercise physiology. J Appl Physiol 2008;104:1553-6.

Conflict of Interest:

The paper by Plum et al. (1) prompted us to verify how fourth year
medical students performed in choosing the initial dose and route of
administration of adrenaline in the treatment of adult anaphylaxis. The
question was one of the 20 they had to answer by blackening the correct
box (C for this specific question) to pass the Clinical Immunology (CI)
exam. Many (approximately two-thirds) of the 192 students who resp...

The paper by Plum et al. (1) prompted us to verify how fourth year
medical students performed in choosing the initial dose and route of
administration of adrenaline in the treatment of adult anaphylaxis. The
question was one of the 20 they had to answer by blackening the correct
box (C for this specific question) to pass the Clinical Immunology (CI)
exam. Many (approximately two-thirds) of the 192 students who responded to
the multiple choice question had attended the 16 hour CI course, which
included one and a half hour lecture on the causes, clinical
presentation, diagnostic criteria, differential diagnosis and management
of anaphylaxis according to the WAO guidelines (2) only about one month
before .
The multiple choice question was A. 500 mg IM, B. 500 mg IV, C. 500
micrograms IM, D. 500 micrograms IV, E. 500 micrograms SC.
Only 45% chose the correct dose and route. 62 out of 192 (32%) chose the
wrong dose (500 mg) and the correct route (IM) while 13% (25 out of 192)
the correct dose (500 micrograms)and the wrong route (either IV or SC).
Eighteen medical students (9%) would have inappropriately given 500 mg IV
to their anaphylaxis patients.
Our medical students did only a little better than Pump et al'. junior
doctors (45% vs 34% chose the correct route and dose, chi square p=0.09)
but still only about half of those who had supposedly been lectured just
one month before undertaking the test were aware of the correct dose and
route of adrenaline for emergency management of anaphylaxis.